Kontraktur Dupuytren

01Pathophysiology

Dupuytren contracture is a fibroproliferative disorder of the palmar fascia (palmar aponeurosis). The disease begins when fibroblasts within the palmar fascia undergo transformation into myofibroblasts, cells with contractile properties similar to smooth muscle. These myofibroblasts proliferate abnormally and deposit excessive amounts of type III collagen, which gradually replaces the normal type I collagen of the fascia. This disordered collagen remodeling is the central driver of disease progression.

The process unfolds in three histological phases. The proliferative phase features rapid myofibroblast multiplication and nodule formation in the palm. The involutional phase sees these cells align along lines of tension and begin actively contracting. Finally, the residual phase is characterized by relatively acellular, mature collagen cords that are permanently shortened. These cords extend from the palm into the digits and mechanically tether the MCP and PIP joints into flexion, which is why the patient progressively loses the ability to extend the affected fingers.

The reason the ring and little fingers are preferentially involved is that the palmar fascia sends its strongest longitudinal fibers (pretendinous bands) to the ulnar digits. The thumb and index finger are relatively spared because their fascial anatomy is different and less prone to cord formation.

An important concept for the exam is Dupuytren diathesis, which refers to an aggressive phenotype associated with bilateral disease, early onset (before age 50), positive family history, and ectopic fibromatosis (such as Garrod pads on the dorsal PIP joints, Ledderhose disease of the plantar fascia, or Peyronie disease of the penile fascia). Recognizing diathesis is tested because it predicts higher recurrence after any intervention.

02Classification and Clinical Manifestation

The Tubiana classification grades severity by total passive extension deficit (the sum of contracture angles at the MCP and PIP joints of a single finger):

Clinical manifestations progress in a predictable sequence:

03Diagnostic Workup

Dupuytren contracture is a clinical diagnosis. This is a high-yield testing point: vignettes will describe the classic findings and the correct answer is to recognize the disease based on history and physical exam alone without ordering additional studies.

The tabletop test (also called the Hueston tabletop test) is the single most practical bedside assessment. The patient is asked to place the affected hand flat on a table surface. If any finger cannot be fully extended to touch the table, the test is positive. A positive result is commonly used as the threshold for considering intervention.

There is no role for biopsy to confirm diagnosis in straightforward cases. Imaging with plain radiographs or MRI is only useful when the examiner needs to exclude other diagnoses such as a soft tissue mass, ganglion cyst, or bony abnormality. If a vignette gives you classic findings and then asks for the "next step," the answer is almost always to proceed directly to treatment rather than ordering imaging or labs.

04Management and Treatment

Observation is appropriate when the patient has a nodule without contracture and no functional complaints. Many patients remain stable for years.

Collagenase Clostridium histolyticum (CCH) is an injectable enzymatic treatment. The dose is 0.58 mg injected directly into a palpable cord. The patient returns 24 to 72 hours later for a manipulation procedure where the physician passively extends the finger to mechanically rupture the enzymatically weakened cord. This is a testable treatment because it is nonsurgical yet effective for isolated cords. Contraindications include injection into cords overlying tendons or neurovascular structures due to risk of rupture or injury. Note that availability varies by region, and in some markets it has been withdrawn.

Needle aponeurotomy is an office-based technique using a standard hypodermic needle (typically 25-gauge) under local anesthesia. The needle is used to repeatedly puncture and divide the cord percutaneously. It is quick, well tolerated, and best suited for MCP joint contractures with a well-defined cord. Recurrence rates are higher than with open surgery, but the procedure is repeatable.

Limited fasciectomy is the most commonly performed surgical procedure and is considered the gold standard when durable correction is needed. The surgeon excises the pathological fascial tissue through palmar and/or digital incisions. It provides the best long-term correction, particularly for PIP contractures, but carries risks including digital nerve or artery injury, wound healing complications, and complex regional pain syndrome.

The indications for intervention that appear on exams are:

• MCP contracture greater than 30 degrees

• Any degree of PIP contracture

• Positive tabletop test

• Functional limitation reported by the patient (difficulty with gripping, handshaking, or placing hand in pocket)

For PIP joint contractures, outcomes are consistently worse than for MCP contractures regardless of the method chosen. This is because the PIP joint develops secondary capsular and ligamentous changes over time that become irreversible. Early intervention for PIP disease is therefore emphasized.

05Differential Diagnosis and Distractors

06Traps and High-Yield Pearls

The most common way students lose points on Dupuytren contracture questions is by ordering unnecessary diagnostic tests. When a vignette describes a middle-aged or older male of Northern European descent with painless palmar nodules and progressive finger flexion contracture, the diagnosis is clinical. Choosing an MRI, biopsy, or rheumatoid factor panel is a classic trap answer. The correct next step is either observation (if no functional deficit) or referral for intervention (if contracture is present).

A second frequent error is confusing Dupuytren contracture with trigger finger. Both involve a finger stuck in flexion. The discriminator is the mechanism: trigger finger involves a snapping, clicking, or locking sensation because the flexor tendon catches at the A1 pulley, and tenderness is localized to the distal palmar crease. Dupuytren has no triggering, no tendon pathology, and features a palpable cord running from the palm into the digit.

Students should also remember that PIP joint involvement carries a worse prognosis than MCP involvement. If a vignette emphasizes PIP contracture, the answer is more likely to involve surgical fasciectomy rather than a minimally invasive approach, because PIP contractures are harder to treat and more prone to recurrence.

Finally, recognizing associated conditions is a tested concept. A vignette that mentions chronic liver disease, epilepsy, or diabetes alongside a hand complaint is steering you toward Dupuytren. The association with Peyronie disease and Ledderhose disease (plantar fibromatosis) under the umbrella of Dupuytren diathesis appears in questions that test your understanding of systemic fibroproliferative tendencies. When you see ectopic fibrosis in combination with palmar disease, the vignette is testing whether you can identify the aggressive phenotype and counsel the patient about high recurrence risk.